Cerebrovascular Accident

DR. RAJESH. T.EAPEN

Overview of Stroke

About 85% of strokes are ischemic, and about 15% are hemorrhagic.

Approximately 795,000 strokes occur each year.

Stroke is the 3rd leading cause of death in the US, and the first cause of death worldwide.

Stroke is a leading cause of adult disability.

History of Stroke

Hippocrates-2,400 yrs ago

Names for Stroke

Most commonly known today

Brain Attack

Demographics of Stroke

Women have about 60,000 more strokes than men.

Native Americans have highest prevalence. African Americans have almost twice the

rate compared to Caucasians. Hispanics have slightly higher rates

compared to non-Hispanic whites. Modifiable risk factors must be addressed in

our aging population with the propensity to stroke.

Definition

Ischemic stroke

Caused by a blocked blood vessel in the brain.

Hemorrhagic Stroke

Caused by a ruptured blood vessel in the brain.

Nursing and Stroke

Nurses play a pivotal role in the care of stroke patients.

Nursing care directed in two phases of the acute stroke experience:

The emergent or hyper-acute phase

The acute phase

Nursing Care of the Stroke

Patient

Stroke is a complex disease requiring the efforts and skills of the multidisciplinary team.

Nurses are often responsible for the coordination of that care.

Coordinated care can result in: improved outcomes, decreased LOS, translating to decrease costs.

Etiology of Ischemic Strokes

20% caused by large vessel athero-thrombotic causes (intracranial or carotid artery)

25% caused by small vessel disease (penetrating artery disease)

20% caused by cardiac sources (cardio-embolism)

30% from unknown causes

Risk factors for Ischemic

Stroke

Hypertension Diabetes Heart Disease Smoking High Cholesterol Male gender Age Ethnicity/Race

CT Scan–Right Occipital/Parietal

Infarction

Ischemic Stroke

Most patients with ischemic stroke do not have a decreased level of consciousness in the first 24 hours

May progress in the first 72 hours

Embolic stroke

Majority of emboli originate in the inside layer of the heart, with plaque breaking off from the endocardium and entering the circulation

Patient with an embolic stroke commonly has a rapid occurrence of severe clinical symptoms

Transient Ischemic Attack (TIA)

Transient ischemic attack (TIA) is a temporary focal loss of neurologic function caused by ischemia

Most TIAs resolve within 3 hours

TIAs are a warning sign of progressive cerebrovascular disease

Caused by a primary either intra-cerebral hemorrhage or subarachnoid hemorrhage.

Etiology of Hemorrhagic Stroke

SAH 3%

ICH 10%

Ischemic vs. Hemorrhagic

CT Scan Right Subcortical Intra-

cerebral Hemorrhage

Risk Factors for Hemorrhagic

Stroke

Hypertension

Bleeding disorders

African American race

Vascular malformation

Excessive alcohol use

Liver dysfunction

Risk Factors

Non Modifiable

Age

Gender

Race

Heredity

Risk Factors

Modifiable

Obesity

HTN

Smoking

Heavy alcohol consumption

Hypercoagulability

Hyperlipidemia

Asymptomatic carotid stenosis

Diabetes mellitus

Heart disease, atrial fibrillation

Oral contraceptives

Physical inactivity

Sickle cell disease

Blood supply by arteries

Blood is supplied to the brain by two major pairs of arteries

Internal carotid arteries

Vertebral arteries

Blood supply by arteries

Carotid arteries branch to supply most of the

Frontal, parietal, and temporal lobes

Basal ganglia

Part of the diencephalon

Thalamus

Hypothalamus

Blood supply by arteries

Vertebral arteries join to form the basilar artery, which supply the

Middle and lower temporal lobes

Occipital lobes

Cerebellum

Brainstem

Part of the diencephalon

Review of Cerebral Circulation

Common sites for the

development of Atherosclerosis

Clinical Manifestations

Affects many body functions Motor activity

Elimination

Intellectual function

Spatial-perceptual alterations

Personality

Affect

Sensation

Communication

The 5 Key Stroke Syndromes:

Classic Signs Referable to

Different Cerebral Areas

Left (Dominant Hemisphere)

Left gaze preference

Right visual field deficit

Right hemiparesis

Right hemisensory loss

Right (Nondominant Hemisphere)

Right gaze preference

Left visual field deficit

Left hemiparesis

Left hemisensory loss neglect (left hemi-inattention)

The 5 Key Stroke Syndromes: Classic Signs Referable to Different Cerebral Areas

Brainstem Nausea and/or vomiting Diplopia, dysconjugate

gaze, gaze palsy Dysarthria, dysphagia Vertigo, tinnitus Hemiparesis or

quadriplegia Sensory loss in hemibody

or all 4 limbs Decreased consciousness Hiccups, abnormal

respirations

Cerebellum Truncal/gait ataxia Limb ataxia neck

stiffness

Clinical Manifestations

Motor Function

Most obvious effect of stroke

Include impairment of

Mobility

Respiratory function

Swallowing and speech

Gag reflex

Self-care abilities

Clinical Manifestations

Motor Function

An initial period of flaccidity may last from days to several weeks and is related to nerve damage

Spasticity of the muscles follows the flaccid stage and is related to interruption of upper motor neuron influence

Clinical Manifestations

Communication

Patient may experience aphasia when a stroke damages the dominant hemisphere of the brain

Aphasia is a total loss of comprehension and use of language

Clinical Manifestations

Communication

Dysphasia refers to difficulty related to the comprehension or use of language and is due to partial disruption or loss

Dysphasia can be classified as nonfluent or fluent

Clinical Manifestations

Communication

Dysarthria does not affect the meaning of communication or the comprehension of language

It does affect the mechanics of speech

Clinical Manifestations

Affect

Patients who suffer a stroke may have difficulty controlling their emotions

Emotional responses may be exaggerated or unpredictable

Clinical Manifestations

Intellectual Function

Both memory and judgment may be impaired as a result of stroke

A left-brain stroke is more likely to result in memory problems related to language

Clinical Manifestations

Spatial-Perceptual Alterations

Stroke on the right side of the brain is more likely to cause problems in spatial-perceptual orientation

However, this may occur with left-brain stroke

Clinical Manifestations

Spatial-Perceptual Alterations

Spatial-perceptual problems may be divided into four categories

1. Incorrect perception of self and illness

2. Erroneous perception of self in space

Clinical Manifestations

Spatial-Perceptual Alterations

3. Inability to recognize an object by sight, touch, or hearing

4. Inability to carry out learned sequential movements on command

Clinical Manifestations

Elimination

Most problems with urinary and bowel elimination occur initially and are temporary

When a stroke affects one hemisphere of the brain, the prognosis for normal bladder function is excellent

Emergent Stroke Workup

All patients Non-contrast brain CT or brain MRI Blood glucose Serum electrolytes/renal function tests ECG Markers of cardiac ischemia Complete blood count, including platelet

count Prothrombin time/INR aPTT Oxygen saturation

Emergent Stroke Workup

Selected patients Hepatic function tests Toxicology screen Blood alcohol level Pregnancy test Arterial blood gas tests (if hypoxia is

suspected) Chest radiography (if lung disease is

suspected) Lumbar puncture (if SAH is suspected and

CT scan is negative for blood) EEG (if seizures are suspected)

Collaborative Care

Prevention

Goals of stroke prevention include

Health management for the well individual

Education and management of modifiable risk factors to prevent a stroke

Collaborative Care

Prevention

Antiplatelet drugs are usually the chosen treatment to prevent further stroke in patients who have had a TIA

Aspirin is the most frequently used anti-platelet drug

Collaborative Care

Prevention

Surgical interventions for the patient with TIAs from carotid disease include

Carotid endarterectomy

Transluminal angioplasty

Stenting

Extracranial-intracranial bypass

Once a potential stroke is suspected, EMS personnel and nurses must determine the time at which the patient was last known to be well (last known well time).

This time is the single most important determinant of treatment options during the hyperacute phase.

Collaborative Care

Hyperacute Care

From the Field to the ED:

Stroke Patient Triage and Care

EDs should establish standard operating procedures and protocols to triage stroke patients expeditiously.

Standard procedures and protocols should be established for benchmarking time to expeditiously evaluate and treat eligible stroke patients with rtPA.

Target treatment with rtPA should be within 1 hour of the patient’s arrival in the ED.

Eligible patients can be treated between the 3-4.5 hour window when carefully evaluated carefully for exclusions to treatment.

EMERGENCY NURSING INTERVENTIONS IN THE EMERGENCY/HYPERACUTE PHASE OF STROKE: The First 24 Hours

Stroke symptoms can evolve over minutes to hours.

Nurses should be aware of unusual stroke presentations.

ED assessments include: Neurological assessment, vital signs + temperature, and should be done not less than every 30 minutes.

Intensive Monitoring

30% of patients will deteriorate in the first 24 hours.

Intensive monitoring by nurses trained in stroke is very important

Trained in neurological assessment

Trained in monitoring of bleeding complications (major and minor)

Ongoing management of blood pressure, temperature, oxygenation, and blood glucose

Collaborative Care

Acute Care

Assessment findings Altered level of consciousness

Weakness, numbness, or paralysis

Speech or visual disturbances

Severe headache

↑ or ↓ heart rate

Respiratory distress

Unequal pupils

Collaborative Care

Acute Care

Interventions – Initial

Ensure patient airway

Remove dentures

Perform pulse oximetry

Maintain adequate oxygenation

IV access with normal saline

Maintain BP according to guidelines

Collaborative Care

Acute Care

Interventions – Initial

Remove clothing

Obtain CT scan immediately

Perform baseline laboratory tests

Position head midline

Elevate head of bed 30 degrees if no symptoms of shock or injury

Collaborative Care

Acute Care

Interventions – Ongoing

Monitor vital signs and neurologic status

Level of consciousness

Motor and sensory function

Pupil size and reactivity

O2 saturation

Cardiac rhythm

Collaborative Care

Acute Care

Recombinant tissue plasminogen activator (tPA) is used to

Reestablish blood flow through a blocked artery to prevent cell death in patients with acute onset of ischemic stroke symptoms

Collaborative Care

Acute Care

Thrombolytic therapy given within 3 hours of the onset of symptoms

↓ disability

But at the expense of ↑ in deaths within the first 7 to 10 days and ↑

in intracranial hemorrhage

Collaborative Care

Acute Care

Surgical interventions for stroke include immediate evacuation of

Aneurysm-induced hematomas

Cerebellar hematomas (>3 cm)

Nursing Management during the

Acute Phase of CVA Objectives of care during the acute phase:

(a) Keep the patient alive.

(b) Minimize cerebral damage by providing adequately oxygenated blood to the brain.

Support airway, breathing, and circulation.

3. Maintain neurological flow sheet with frequent observations of the following:

(a) Level of consciousness.

(b) Pupil size and reaction to light.

(c) Patient's response to commands.

(d) Movement and strength.

(e) Patient's vital signs--BP, pulse, respirations & temperature.

(f) Be aware of changes in any of the above.

Deterioration could indicate progression of the CVA.

Nursing Management during the Acute Phase of CVA

Nursing Management during the Acute Phase of CVA

4. Continually reorient patient to person, place, and time (day, month) even if patient remains in a coma. Confusion may be a result of simply regaining consciousness, or may be due to a neurological deficit.

5. Maintain proper positioning/body alignment. (a) Prevent complications of bed rest. (b) Apply foot board, sand bags, trochanter rolls,

and splints as necessary. (c) Keep head of bed elevated 30º, or as

ordered, to reduce increased intracranial pressure.

(d) Place air mattress or alternating pressure mattress on bed and turn patient every two hours to maintain skin integrity.

Nursing Management during the Acute Phase of CVA

6. Ensure adequate fluid and electrolyte balance.

(a) Fluids may be restricted in an attempt to reduce intracranial pressure (ICP).

(b) Intravenous fluids are maintained until patient's condition stabilizes, then naso-gastric tube feedings or oral feedings are begun depending upon patient's abilities.

7. Administer medications, as ordered

(a) Anti hypertensives.

(b) Antibiotics, if necessary.

(c) Seizure control medications.

(d) Anticoagulants.

(e) Sedatives and tranquilizers are not given because they depress the respiratory center and obscure neurological observations.

Nursing Management during the Acute Phase of CVA

8. Maintain adequate elimination

(a) A Foley catheter is usually inserted during the acute phase; bladder retraining is begun during rehabilitation.

(b) Provide stool softeners to prevent constipation. Straining at stool will increase intracranial pressure.

9. Include patient's family and significant others in plan of care to the maximum extent possible.

(a) Allow them to assist with care when feasible.

(b) Keep them informed and help them to understand the patient's condition.

Rehabilitation of the patient

with CVA Process of setting goals for rehabilitation must

include the patient. This increases the likelihood of the goals being met.

Rehabilitation of the patient

with CVA General rehabilitative tasks faced by the patient

include: *Learning to use strength and abilities that are

intact to compensate for impaired functions. *Learning to become independent in activities of

daily living (bathing, dressing, eating). *Developing behavior patterns that are likely to

prevent the recurrence of symptoms. *Taking prescribed medications. *Stopping smoking. *Reducing day-to-day stress. *Modifying diet.

Rehabilitation CVA

Specific teaching, encouragement, and support are needed.

Individualized exercise program involving both affected and unaffected extremities is required.

Speech therapy, as indicated by patient's condition, may be necessary.

Continuous revaluation of goals and patient's ability to meet the goals is required to maintain a realistic plan of care.

Counseling and support to family is an integral part of the rehabilitation process.

-Both family and patient need direction and support in coping with intellectual and personality impairment.

-Instruct family to expect some emotional lability such as inappropriate crying, laughing, or outbursts of temper.